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Lesson name: Trauma Triad of Death

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v There isnt nearly as much that we, as prehospital providers, can do for trauma
patients compared to medical patients.
BLS skills such as controlling bleeding and managing the airway.
Trauma is a surgical disease, i.e. only surgeons can cure it.
v However, there are preventable causes of death in trauma. Understanding some of
the pathophysiology of trauma can help us to help our patients.
v Three factors have been identified as the leading causes of death in trauma patients.
These factors actually feed one another, and have come to be known as the triad
of death.1
Hypothermia when a patients core body temperature gets too low (core
temperature <35C/95F).
One study showed that almost half of all trauma patients brought to the
hospital by EMS were hypothermic upon arrival.2
A study showed that every single trauma patient whose core temperature
dropped to 32C/90F or below died.3
Acidosis when a patients blood becomes too acidic (pH < 7.2).
The body has a very low tolerance for changes in pH (normal: 7.357.45).
Acidosis can cause impaired cardiac performance, decreased
responsiveness to cardiac inotropic drugs, [and] decreased renal perfusion.4
Prehospital providers can unknowingly contribute to acidosis by administering
large amounts of normal saline.4
Normal saline (0.9% sodium chloride)
Coagulopathy when a patient loses the ability to form clots and stop bleeding
(INR [international normalized ratio] > 1.5).
One review found that up to a third of trauma patients are coagulopathic upon
arrival to the ED.5
In one study, patients with extreme coagulopathy had a mortality rate of
100%.1

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Lesson name: Trauma Triad of Death
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Hypothermia

Acidosis Coagulopathy

v Patients who present to trauma centers with those three conditions have a mortality
rate of about 50%1; another study found it was nearly 70%6; the US Army estimates
that it can be as high as 90%7. In other words, if we let our patients develop these
three conditions then weve just given them, at best, a 50/50 chance of living or
dying.
v The most frightening thing about the trauma triad of death is that each of the three
factors contributes to another of the factors, hence what was said earlier about them
feeding each other.
Bleeding initially causes coagulopathy.
As the patient bleeds, they lose their clotting factors.
Hypothermia worsens coagulopathy.8
Clots cant form when the temperature of the blood is too low.
Coagulopathy worsens acidosis.9
As a patient bleeds, they lose the ability to perfuse tissues. As tissues lose
perfusion, they begin to undergo anaerobic metabolism. One of the
byproducts of anaerobic metabolism is lactic acid. As lactic acid accumulates
in the poorly perfused tissues, the body enters metabolic acidosis.
Acidosis worsens both hypothermia and coagulopathy.10
As the body becomes more and more acidic, the cardiac cells become more
irritable and less effective. Since flowing blood is the most important heat-

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Lesson name: Trauma Triad of Death
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exchange pathway inside the body11, decreased cardiac output means the
body loses its ability to warm itself (thermoregulation).
Additionally, many patients have baseline coagulopathy. These include
patients who routinely take blood-thinning medications, such as
heparin/Coumadin.
v What can we do? How can we prevent the trauma triad of death?
Hypothermia is something we definitely can control in the prehospital setting.
Exposure. We are trained to remove a patients clothes in order to perform a
full physical exam. This is good, but what happens when were done with the
exam? Do we cover the patient up with a blanket, or do we leave them lying
naked and exposed to the air?9,12 Turn up the temperature in the back of
the ambulance, even if you as a provider are uncomfortable, and cover the
patient with a blanket when possible.
IV fluids. Fluids are usually kept at room temperature, which is colder than
the bodys normal temperature. When we introduce these fluids directly in to a
patients bloodstream via an IV, we can significantly lower their core
temperature.12 If you have the required equipment or supplies, give warmed
IV fluids instead of colder, room temperature fluids.
Acidosis is a little bit harder to address in the prehospital setting. Most agencies
carry sodium bicarbonate, which can be used to reverse acidosis. However, it
must be given in a very controlled manner in order to prevent overshooting and
causing alkalosis. Some EMS agencies are starting to carry point-of-care blood
chemistry tests (e.g. i-STAT) that can tell you the patients blood pH and allow
you to calculate the required dose of bicarb. If your agency has such capability,
consult with your medical director about the possibility of a protocol to treat
diagnosed acidosis.
Giving a crystalloid other than normal saline (e.g. lactated Ringers solution)
will not reverse acidosis, but it can reduce a patients risk of developing
acidosis.4 One literature review concluded that lactated Ringers solution is
suitable for resuscitation in many cases, and that the routine use of [normal
saline] in massive fluid resuscitation should be discouraged4 (emphasis
added). This can be a good strategy to stay ahead of the curve and
proactively prevent the triad of death, instead of reactively trying to fix it once
it sets in. An ounce of prevention is worth a pound of cure.
Coagulopathy is arguably the toughest of the three factors to treat in the
prehospital setting.

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Lesson name: Trauma Triad of Death
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The most definitive treatment is the administration of blood products. If your

agency has a protocol for this, consult with your medical director to learn
more about it.
Tranexamic acid, or TXA, can help improve the bodys ability to clot. TXA has
gained a lot of traction with military providers, and now some civilian EMS
agencies are adopting TXA in to their protocols.13
As with the acidosis recommendations above, an ounce of prevention is worth
a pound of cure. There are several things prehospital providers can do to
prevent coagulopathy from setting in.
Stop the bleeding. None of the other interventions will matter if the
patient continues to bleed.
Limiting fluid administration may have multiple benefits.
Excessive fluid administration dilutes clotting factors, contributing to
coagulopathy.5
Normal saline specifically is fairly acidic, and in large amounts, can
contribute to acidosis.4
As stated earlier, most fluids carried in ambulances are not warmed,
and can contribute to hypothermia.
The American College of Surgeons, in its Advanced Trauma Life
Support (ATLS) guidelines, has reduced its initial fluid administration
recommendation from 2 liters down to 1 liter.14
Some data also support the use of impedance threshold devices, such as the
ResQPod. ITDs maintain a negative intrathoracic pressure and can improve
perfusion of the vital organs during shock. One study showed that pigs in
hypovolemic shock with an ITD and no fluid administration had a systolic blood
pressure increase of 1015 mmHg over pigs with no ITD.15

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Lesson name: Trauma Triad of Death
Lesson
Trauma
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References
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